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Patient questions about transplantation: a resource guide.

Article Excerpt
Nurses and other staff in dialysis units are often the primary resource for patients on dialysis to obtain their healthcare information. Kidney transplantation is the preferred renal replacement therapy for many patients, but dialysis staff members are often uncomfortable or unable to answer questions related to transplant evaluation, surgery, medications, potential complications, and patient responsibility. Dialysis units are usually physically removed from transplant centers, and patients may not understand how to obtain information regarding transplantation. Nurses and other staff in dialysis units should be able to address general questions related to transplantation so patients receive consistent information that is repeated over the course of time.

The commitment to transplantation is significant for the potential recipient in terms of time, education, and self-care behavior. Continuous, consistent pre-transplant education will best prepare the patient for a successful transplant experience. Patients who are referred for transplantation receive a high volume of information in visits to the transplant center, which is compressed into a short time and may be forgotten or misunderstood. Patients on the transplant waiting list and/or preparing for live kidney donor transplantation have limited interaction with the transplant center prior to transplant. Optimal pre-transplant education therefore requires a collaborative effort between staff members of the dialysis unit and the transplant clinic.

The purpose of this article is to provide answers to a variety of frequently asked questions about transplantation from patients on dialysis. The goal is to provide a basis for conversations that will be continued in more detail with the transplant team. Included in this discussion are components of the pre-transplant recipient evaluation; medication purpose, side effects, and cost; acute and chronic rejection diagnosis and treatment; and patient commitment for successful transplantation.

Who Is a Transplant Candidate?

The question of who is eligible for transplantation requires consideration of physical, psychological, and financial components. Insurance companies vary in their coverage regulations, but patients are generally eligible for activation on the waiting list and/or to receive a live donor transplant at a creatinine clearance of 20 ml/minute. When patients are referred for transplantation, the first step at the transplant center is to determine the financial coverage regulations that apply for the individual. The point at which insurance companies allow the evaluation to start may vary, as well as when donors may be evaluated. Patients who are already on dialysis simply need a referral to the transplant center, and the transplant center will start the evaluation as soon as financial coverage for transplantation and immunosuppressive medications is established.

The majority of transplant centers require a plan for how the patient will obtain the medications, which can cost over $1000/month. Medicare covers 80% of the cost of medications, but Medicare coverage for immunosuppressive medications currently expires after 3 years. Secondary insurance will often cover the 20% left to the patient and will become primary when Medicare benefits expire (Morrison, 2008). However, if the patient has no secondary insurance, thought must be given to how the patient will cover the 20% co-pay for medications. Medication non-adherence is a frequent cause of graft loss, so the patient really needs to think ahead about how to cover the cost of medications over the long term.

Physically, patients must be free of any major medical or psychological contraindications for elective surgery. Active infection or cancer, severe cardiovascular disease that greatly increases the risk of morbidity or mortality, and significant psychological disorders that inhibit the patient's ability to care for and monitor the transplanted organ are some of the relative contraindications to transplantation. However, many of these problems may resolve or improve over time to the point that a patient may once again become a candidate for transplantation. There is no particular age limit for kidney transplantation because the physiologic age is more pertinent than chronological age (Kahan & Ponticelli, 2000; Steinman et al., 2001). The transplant center's responsibility is to evaluate the patient as a potential transplant recipient and determine if the patient is presently a candidate, possibly a candidate in the future, or if there are any absolute contraindications that preclude transplantation.

What Do I Have to Do to Get a Kidney?

The purpose of the medical evaluation is to search for any evidence of medical conditions that will increase the risk of adverse events or complications during surgery or post-operatively. A kidney transplantation is an elective procedure; the goal is to determine, as much as possible, that the patient is likely to survive general anesthesia without cardiovascular, pulmonary, or other life-threatening event. Maximizing physical condition pre-transplant is likely to decrease...

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